Forest Hill Manor Health Center

In the surveyor’s words

From the most serious findings on record at Forest Hill Manor Health Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 1, 2025

  Based on observation, interview and record review, the facility failed to ensure a resident received adequate monitoring to prevent an elopement (leaving the facility without authorization) for one of two sampled residents (Resident 1). Resident 1's elopement assessment indicated she was at risk for elopement, and a care plan was not developed upon admission. On 6/27/25, Resident 1 eloped, was found the next day on 6/28/25 in the neighborhood, transferred to a hospital, was noted to have hypothermia (significant and potentially dangerous drop in body temperature with most common cause from exposure to cold weather) and sustained injuries of forehead laceration (cut) requiring suturing.This failure resulted in Resident 1 having multiple bodily scratches/abrasions, hypothermia, altered… […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2025

  Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. There were opened, undated, and unlabeled food items in the reach-in refrigerator; 2. There were undated and unlabeled food items in the food preparation area; 3. Pans used for food preparation and food service were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 24 of 24 residents who received their food from the kitchen. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF700Jan 23, 2024

  Based on observation, interview, and record review, the facility failed to follow their bed rails (bed rails, safety rails, side rails, grab/assist bars: adjustable metal or rigid plastic bars that attached to the bed) policy for 12 of 12 sampled residents (Residents 8,178, 179, 184, 181, 12, 132, 4, 20, 7, 13, and 6). The survey team expanded the sample and identified that a total of 25 resident had the bed rails. The facility failed to follow their bed rails policy when: 1.There was no documentation that alternatives for bed rails were attempted prior to installing bed rails for 25 of 25 residents; 2.There was no informed consent (the process of communication between health care provider and resident that often leads to agreement or permission for care, treatment or services or… […]

• No harm, potential for more than minimal, widespreadF812Jan 23, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. The convection oven (a cooking device that heats food) located in the skilled nursing facility (SNF) pantry area was not kept in a sanitary condition; 2. No thermometer inside the freezer designated for the SNF residents; 3. The freezer temperature log was not completed, and multiple times, the temperature was ,d+[DATE] degrees above 0 Fahrenheit (F, a scale of temperature) degree; 4. The freezer designated for the SNF residents had multiple items unlabeled; 5. An opened bag of pasta was not labeled in the dry storage area; 6. The ice machine was not kept in a sanitary condition; 7. […]

• No harm, potential for more than minimal, patternF755Apr 25, 2025

  Based on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) to document medication administration as in accordance with the facility policy and procedures (P&P) and the availability of medication for three out of 13 sampled residents (Resident 10, Resident 9, and Resident 15). These failures had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally) and had the potential for untreated or worsening of patient's medical conditions. Findings: 1. […]